Effects of estrogen replacement therapy on the lipoprotein profile in postmenopausal women with ESRD

BACKGROUND

Patients with ESRD have excessive cardiovascular morbidity and mortality. In postmenopausal women with normal renal function, estrogen replacement therapy decreases cardiovascular mortality by 50%, in part because of their beneficial effects on the lipoprotein profile. Because of similarities in the lipoprotein profile between healthy, postmenopausal women, and women with ESRD, we examined the effects of estrogen replacement on lipoproteins in 11 postmenopausal women with ESRD.

METHODS

In a randomized, placebo-controlled crossover study (8 week treatment arms) using 2 mg daily of oral, micronized estradiol, 11 postmenopausal women with ESRD were treated. Neither baseline lipid nor lipoprotein abnormalities were used as entry criteria for study participation.

RESULTS

Blood estradiol levels were 19 +/- 4 with placebo and 194 +/- 67 pg/ml (P = 0.024) with estradiol treatment. Total HDL cholesterol concentrations increased from 52 +/- 19 mg/dl to 61 +/- 20 mg/dl (16%), with placebo and estradiol treatments, respectively (P = 0.002). Apolipoprotein A1 increased by 24.6% (P = 0.0002) with estradiol intervention. HDL2 concentrations were 19 +/- 13 with placebo and 24 +/- 16 with estradiol treatment (P = 0.046). There were no differences in total or LDL cholesterol, other lipoprotein fractions including Lp(a), and triglycerides with 2 mg daily estradiol treatment. No significant side effects were observed.

CONCLUSIONS

Therefore, using standard dosage regimens for estrogen replacement therapy in postmenopausal women with ESRD, HDL cholesterol is increased to an extent that would be expected to improve their cardiovascular risk profile. Further studies are needed to assess whether estrogen replacement therapy decreases the incidence or severity of cardiovascular disease in ESRD patients to a similar degree compared with other women.

Development and evaluation of a CD-ROM computer program to teach residents telephone management

OBJECTIVE

Under managed care, telephone management is crucial to pediatric practice, but an effective method is needed to teach residents telephone skills. Our objective was to design an interactive CD-ROM program to teach residents an organized, consistent approach to telephone complaints and to determine whether use of the program was associated with better subsequent telephone management than reading the same information.

SETTING

The general pediatric ambulatory center of a tertiary care children's hospital.

PARTICIPANTS

A total of 24 PL-2 and PL-3 pediatric residents.

DESIGN

A randomized, prospective, controlled comparison was conducted of resident management of two telephone calls: a 5-year-old with cough and trouble breathing, and a 7-year-old with fever. Thirteen residents were randomized to the computer group and 11 to the reading control group. Intervention. Scripts, scoring, and feedback for 10 CD-ROM-simulated calls were developed from texts and pediatrician survey using a modified Delphi technique. Volunteers acted out the caller's role in scenario scripts and were recorded onto a CD-ROM. The computer simulated calls by recognizing questions typed in a free-form format and answering with a voice response. Feedback was provided for omissions in history-taking and errors in assessment, triage, and home management. The computer group worked through the CD-ROM calls while the control group had equal time to read the same information. Evaluation Measures. A trained, standardized patient acted as the mother in pretest calls placed at the beginning of the month and posttest calls at the end. Calls were recorded and scored in a blinded manner using scoring templates and on interpersonal skills using the Patient Perception Questionnaire.

RESULTS

Pretest scores for the two calls were similar in the computer versus the control group (cough, 70.33% +/- 8.36 vs 68.46% +/- 6.73; fever, 75.64% +/- 9.82 vs 73.59% +/- 9.06). Posttest scores were significantly higher in the computer group than in the control group on both calls (cough, 79.08% +/- 8.17 vs 69 +/- 13.3; fever: 83.33% +/- 9.96 vs 70.35% +/- 9.66). Interpersonal skills also were similar pretest (19 +/- 3.4 vs 20 +/- 2.7). There was modest improvement in both groups without a statistically significant difference in posttest scores (24.2 +/- 2.9 vs 22.5 +/- 3.1).

CONCLUSIONS

Use of this CD-ROM telephone management program was associated with better postintervention telephone management. The program augments faculty instruction by teaching a consistent, general approach to telephone management.

Forecasting the need for physicians in the United States: the Health Resources and Services Administration's physician requirements model

OBJECTIVE

The Health Resources and Services Administration's Bureau of Health Professions developed a demographic utilization-based model of physician specialty requirements to explore the consequences of a broad range of scenarios pertaining to the nation's health care delivery system on need for physicians.

DATA SOURCE/STUDY SETTING

The model uses selected data primarily from the National Center for Health Statistics, the American Medical Association, and the U.S. Bureau of Census. Forecasts are national estimates.

STUDY DESIGN

Current (1989) utilization rates for ambulatory and inpatient medical specialty services were obtained for the population according to age, gender, race/ethnicity, and insurance status. These rates are used to estimate specialty-specific total service utilization expressed in patient care minutes for future populations and converted to physician requirements by applying per-physician productivity estimates.

DATA COLLECTION/EXTRACTION METHODS

Secondary data were analyzed and put into matrixes for use in the mainframe computer-based model. Several missing data points, e.g., for HMO-enrolled populations, were extrapolated from available data by the project's contractor.

PRINCIPAL FINDINGS

The authors contend that the Bureau's demographic utilization model represents improvements over other data-driven methodologies that rely on staffing ratios and similar supply-determined bases for estimating requirements. The model's distinct utility rests in offering national-level physician specialty requirements forecasts.

The use of anabolic-androgenic steroids by Canadian students

OBJECTIVE

To assess the prevalence of use of anabolic-androgenic steroids and other presumed performance-enhancing drugs and the associated knowledge, attitudes, and behavior of school-aged Canadians.

DESIGN

A national survey was conducted using a self-report questionnaire distributed randomly to schools within each of five Canadian regions.

SETTING

Canada.

SUBJECTS

The subjects were 16,119 Canadian students, in the sixth grade and above, from 107 schools drawn randomly from five Canadian regions.

MAIN OUTCOME MEASUREMENTS

The number of students reporting the use of anabolic-androgenic steroids and other performance-enhancing drugs in the year before the survey, the nature of such drug-taking activities, and the attitudes underlying the decision to take anabolic-androgenic steroids.

RESULTS

More than 83,000 young Canadians (2.8% of the respondents) are estimated to have used anabolic-androgenic steroids in the year before the survey. Of those taking such drugs, 29.4% reported that they injected them; of the latter group, 29.2% reported sharing needles in the course of injecting anabolic-androgenic steroids. Significant numbers of respondents reported using other substances (caffeine, 27%; extra protein, 27%; alcohol, 8.6%; painkillers, 9%; stimulants, 3.1%; "doping methods," 2.3%; beta-blockers, 1%) in attempts to improve sport performance.

CONCLUSIONS

The use of anabolic-androgenic steroids is more widespread than may have been assumed and is often accompanied by high-risk needle-sharing. Anabolic-androgenic steroid use is often intended to alter body build as opposed to accentuating sport performance. Many young Canadians use a variety of other substances in attempts to improve sport performance. Drug-taking of this kind represents a special challenge for educators, health professionals, and sport authorities.

Identification of abuse in emergency departments: effectiveness of a two-question screening tool

OBJECTIVE

A national health objective for the year 2000 is that at least 90% of hospital emergency departments have protocols for routine identification, treatment, and referral for victims of spouse abuse. An effective assessment tool is needed to implement such protocols.

METHODS

To test the effectiveness of a two-question, nurse-administered, screening tool to detect physical abuse, 416 black, Hispanic, and white women coming to public and private emergency departments with vaginal bleeding were asked two questions. Additionally, a 14-item Danger Assessment Scale to determine risk factors of homicide was administered to all women.

RESULTS

In response to the two-question abuse assessment screen, 38% of the 416 women reported a history of physical or sexual abuse. For 61% of the women, the last episode of abuse occurred within the last 12 months. White women reported significantly more abuse than other ethnic groups (chi 2 = 18.71; df = 2; p = 0.00009). Teenagers reported more risk factors of homicide.

DISCUSSION

Abuse to women who seek care in emergency departments is common and easily detected with a straightforward two-question screen. Universal assessment and accompanying information on safety and community resources is essential to interrupt abuse, prevent further trauma and potential homicide, and promote the health and safety of women.

The pediatric clerkship director. Support systems, professional development, and academic credentials

Since the advent of the clerkship at The Johns Hopkins Medical School in the late 19th century, this model has been the backbone of clinical training for medical students throughout the world. Despite the pervasiveness of clerkships, little information exists about the faculty that oversees them administratively. We documented the reported academic credentials, professional development, and support systems for pediatric clerkship directors in the United States and Canada. Our findings should be useful to clerkship directors and department chairpersons across disciplines.

Current emergency department management of stroke in Houston, Texas

BACKGROUND AND PURPOSE

This study describes emergency department (ED) management of stroke in Houston, Tex, in 1992 to identify delays and deficiencies in recognition and management of stroke patients in various hospital subtypes and to quantitate the impact of a rapid response stroke team.

METHODS

ED logs of eight hospitals were retrospectively screened, and 112 patients with suspected acute stroke onset within 6 hours were identified. EDs were divided into four groups based on hospital size (175 to 979 beds), acuity, number of stroke admissions (50/y to 210/y), and availability of neurological consultations. The intervals from stroke onset to triage, examination by a physician, neurological evaluation, computed tomography (CT) and other tests, vital signs, and treatments were recorded.

RESULTS

The average time from stroke to ED arrival was 115 minutes, and times from ED arrival to examination by a physician and CT scan were 28 and 100 minutes, respectively, with little variability among hospital groups except that the public hospital was slower. Neurological examinations were poorly documented in community and public hospitals. The presence of a stroke team shortened the time to examination by a physician and to CT by 13 and 63 minutes, respectively, and increased the number of patients admitted to the intensive care unit. Blood pressure was excessively lowered in 31% of hypertensive patients, and hypotonic dextrose intravenous fluids were given to 69% of all patients.

CONCLUSIONS

Transport, initial evaluation, and ED care of acute stroke patients are currently slow and often inexpert in all types of hospitals. A stroke team can speed initial ED management.

Foot care data from two recent nationwide surveys. A comparative analysis

On the issues of incidence and prevalence: Specific Foot Problems. At the national level, ie, all respondents combined, the agreement between the NHIS and BrimmComm findings is remarkably close. Much of the difference, if not all, is believed explainable by the approximately 5% shortfall in the reported rate of problems associated with individuals who failed or refused to report their income. Where there are major differences between the NHIS and BrimmComm findings, they occur chiefly when the data are disaggregated by sex, age, or income. Technically speaking, the differences are in most cases statistically insignificant because of the generally small sample sizes associated with individual population segments in the BrimmComm survey. Injuries. Although the differences here are somewhat greater than they are for other foot problems, this may be the result of the greater emphasis being placed in the BrimmComm survey (as opposed to the NHIS) on the reporting of injuries. On the issue of utilization: Basic Treatment Patterns. Nothing in the BrimmComm data refutes the observation that podiatrists remain the provider of choice for toenail problems, corns and calluses, and bunions, and are a strong second to MDs for the treatment of foot infections. Overall Number of Visits. The BrimmComm data would indicate a total of 41.4 million visits involving patients 18 years and older in a period of 12 months. Following technical adjustments described in the text (including augmentation to include patients 17 years of age or younger), the total number of visits to podiatrists in 1990 involving civilian noninstitutionalized patients is believed to be in the vicinity of 50 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Work redesign: an overview

The process of redesign offers many opportunities to staff and leadership; it can be an exciting process with the potential for positive outcomes for staff, management, and patients. The key to success is to work together as a team to design new care teams and revised systems to enhance the quality of care provided. Changes will be and are taking place in health care. Nurses have the opportunity to use their creativity and innovation to help shape the future of health care. Emergency nurses can help accomplish this transformation and maintain our tradition as patient advocates for access to care and safe, quality patient care. This article has provided an overview of the major issues that should be addressed in a redesign project. Future articles will describe the redesign projects of specific emergency departments, highlighting strategies for planning and implementation.

Identification of residues important for ligand binding to the human 5-hydroxytryptamine1A serotonin receptor

The functional significance of the conserved amino acids within transmembrane regions II and VII of the human 5-hydroxytryptamine (5-HT)1A receptor was analyzed by oligonucleotide-directed mutagenesis followed by transient expression of the mutated receptor genes in COS-1 cells. The substitution of a conserved asparagine at position 396 (transmembrane region VII) with either alanine, phenylalanine, or valine resulted in a receptor that did not bind the 5-HT1A agonist 8-hydroxy-2-(di-n-[3H]propylamino)tetralin. In contrast, replacement of Asn396 with glutamine did not affect agonist binding. In addition, serine residues at positions 391 and 393 (transmembrane domain VII) were changed to alanine. Changing the less conserved Ser391 to alanine had no effect on ligand binding. However, replacement of the conserved Ser393 with alanine reduced ligand binding by 86%. Replacement of a conserved aspartate at position 82 (transmembrane region II) with alanine also produced a receptor without detectable agonist binding. Protein immunoblotting detected receptor protein of approximately 51 kDa in both wild-type and mutant receptor-expressing cells, indicating that these mutations probably did not affect expression or processing of the protein. Importantly, the sequence of the human 5-HT1A receptor described in this paper differs from the published sequence [Nature (Lond.) 329:75-79 (1987)] in transmembrane region IV. The present sequence encodes a protein of 422 amino acids, instead of the 421-amino acid protein that has been described previously [Nature (Lond.) 329:75-79 (1987)], and has a change in the sequence in transmembrane region IV from ... RPRAL ... to ... RRAAA ..., which corresponds to the published sequence [J. Biol. Chem. 265:5825-5832 (1990)] of the rat 5-HT1A receptor. Moreover, conversion of the transmembrane region IV sequence of the present clone to that of the published sequence by site-directed mutagenesis abolished ligand binding to the receptor.

Comparison of integrated systemic and emotionally focused approaches to couples therapy

This study compared couples receiving two marital therapy approaches and a control group over a 10-week treatment period. Integrated systemic therapy (IST) and an emotionally focused approach (EFT) were both found to be superior to the control and to be equally effective in alleviating marital distress, facilitating conflict resolution and goal attainment, and reducing target complaints at termination. IST couples, however, showed greater maintenance of gains from termination to 4-month follow-up on marital satisfaction and goal attainment. Clients' perceptions of how change occurred and issues related to the use of a team of observers in IST are discussed.

Family therapy in the treatment of adolescents

A family with an adolescent must transform itself from a predominantly nurturant unit to one that can tolerate and encourage the adolescent's need to separate. When an adolescent presents with symptoms that disrupt the developmental process, the clinician who is familiar with several models of family therapy is better able to select a therapeutic and cost-effective intervention. For family assessments, the authors recommend a biopsychosocial approach, which has replaced the outdated view that families cause psychiatric problems and which acknowledges the family as a potential source of healing. The authors describe several models of family therapy--Satir's communication model, the structural model of Minuchin, Bowen's cross-generational model, and psycho-education--and examine features of these approaches useful for working with adolescents. Illustrative vignettes and some guiding principles for matching model and problem are offered.